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li 1`t-IT a,. it �i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERfILE RECORD INFORMATION FORM ❑New EH Pro ram at ExlsUn Facill ❑New EH P ram and Foclll Faolll ID Pro ram RsooM ID �u Facility Address � .IMmm,atign.) size,number o}units end�y�^��- ' (Please check the appropdate desorlpUon and specify_ ' FOOD PROGRAM(1600) Food Handlers Course required' Yes 1B No ❑ ❑Restaurant: Seating Capacity_. Square Footage ❑Vending Machines Number of Units (TCommissary 11Dry storage only (9with Food Preparation ❑ Retail Market--Square footage ❑wiMeal Market only ❑ Multiple Departments❑ Prepackaged Goods only Vehicle Type� Color ❑ Mobile Food Vehicle r Make License#�-_--- SbckColor Registration# Vehicle T Color [] Mobile Food Prep UrltMake— y� Sticker#�� Registration# License# to [I ice Plant� Produce Stand ❑ Temporary Food Facility-Dates of operation from to ❑ CFO 0❑ B ❑ Special Event-Dates of operation from I DAIRY PROGRAM(2000) [3MIIk Dispenser-Number of Containers in MUili-Head Unit 13 Grade A Dalry ❑ Grade B Dalry COPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)--->-Tons Generated Per Year. ❑ Tiered Permitting Faclllty—> OCA(2232) ❑CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program(UST)(2300)Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) C1❑ HotellMotel--Number of Units Jall or Exempt Institution—Number of Units Employee Housing(2700)Use Emplo ee Housina/Labor Camp Application Form NTROL(3000) SITE MITIGATION(2900) UNDERGROUND INJECTION COT 11 Environmental Assessment [3 UST-CAP Site [I Local HW Cleanup Site ❑ NPLISEP Cleanup Site [3 Abandoned HW Site ❑ non-NPLJSEP Cleanup Site ❑ RWOCB Cleanup Site El Water I Water Quality MAR RECREATIONAL H21 EALTH PROGRAM(3600) ff2bb333 �. Number of Pools/Spas at Faahry _ ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing A Illlh SF NJO401MENT0 TY E ILTH 00M RIME VECTOR CONTROL PROGRAM(4000) ❑ Kenn�IAUN OFMp{MEN/ ❑ Poultry Farm---Mawmum number of birds TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) Cl Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑Body Art Temp Event Coord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LI QUID LIgUIDVygS_ S PROGRAM(4200) ❑ Pumper VehlcleEgistration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Unds SOLIDSOLID WASTE PROGRAM g ❑ Sludge/Ash a/Ash Site ❑ Landfill ❑ Transfer Station ❑ AglCannery Waste Site [:1Waste Tire Facility [I Compost Facility 1:1 ❑ CIA Landfill Site ProcesslRecycle Facility ❑ FarmlRanch Cleanup Site C1 Refuse Vehicles(A of unnxl 13Dumpsters>20 cu yd Is or Units) _ P MEDICAL WASTE PROGRAM(4500) ❑ Primary Care ❑ Acute Care ❑ Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 011 -60 ❑ >60 generators wI Ic WATER SYSTEM PROGRAM(4600)Use PWS EHD 46-02-003 Blue Application Form EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM CONTACT PERSON ' '� Day Ph h.7' Al Night Ph PROGRAM ELEMENT FEE /4.-/.-'�J='J��❑ surch#ge F ❑ Other FEE INSPEC OR# 1 , PERMIT VALID-� I t0 ❑ Food Hand r I✓� 2 Z �Z' - AMOUNT PAID t S� Date Z( INVOICE# Check# REVIEWED BY ACCOUNTING OFFICE Date ❑ Cash MASTERFILE RE O 0 NFORMATION PINK trzyi?� ( # 2? >_7� ,I ( L